Thyroid eye disease and Orbital Decompression

What is thyroid eye disease?

Thyroid eye disease or Graves' Orbitopathy or Graves' Ophthalmopathy is an autoimmune disorder that can affect the muscles and fat tissue around the eye within the eye socket. It can cause the eyelids to become swollen and inflamed with lid retraction giving a bulging appearance. The orbital fat around the eye can expand causing further bulging. The bulging together with swelling or scare tissue to the muscles that move the eye can cause double vision and in rare cases it can create pressure on the optic nerve and lead to vision loss. This is known as optic neuropathy.

What are the symptoms of Graves' eye disease?

The inflammation that occurs to the tissues around the eye cause:

Redness of the eyelids and the eye
Pain at rest or on eye movement
Swelling of the eyelids, eyeball
Bulging of the eyes
Dry eye and irritation
Increased pressure within the eye socket
Double vision from swelling and scarring of the eye muscles
Decreased vision

How do you treat bulging eyes from Graves' disease?

Mr Ahmad Aziz in his London clinic believes the best treatment to prevent bulging eyes it to prevent it in the first place. This is achieved by ensuring

The thyroid gland hormones are in balance with medication as soon as possible to treat the thyroid disease.
Making sure that you stop smoking if you are a smoker as this can make the condition worse and last for a longer period of time.
Taking selenium supplements in mild cases which is shown to improve outcomes
Treating active disease early with corticosteroids. Taken intravenously is less convent but is shown to result in fewer Cushing's side effects.
Considering autoimmune condition medications early if steroids do not help, examples of this include a medication known as Mycophenolate Mofetil or Azathiaprine.
Radiation therapy or orbital radiotherapy to the eye sockets in severe cases where the person affected is over the age of 30.
Avoiding radioactive iodine treatment for their Graves' disease if they already have significant signs of ophthalmopathy.
Considering orbital decompression surgery to restore the position of the eyes if there is bulging already, there is no longer an underachieve or overactive thyroid gland and the eyes have been stable for many months.

Does everyone with graves get bulging eyes?

About 30% of those with Graves disease get some form of Graves ophthalmopathy. Bulging of the eyes is not common and most cases do not develop this particularly if the Graves' is treated early.

How do you get thyroid eye disease?

This is an autoimmune disease that is associated with an imbalance of the hormone levels from the thyroid. As the immune system affects the thyroid it can also affect the eye sockets, activating cells known as orbital fibroblasts. The disease process is further enhanced with smoking and possibly other conditions such as Rheumatoid arthritis and Diabetes Mellitus. Progression of the inflammation can lead to swelling, redness, pain, and visual problems with the eyeball no longer maintaining its normal position and moving forwards giving proptosis or bulging.

What is the treatment?

The inflammation commonly results in dry eyes and irritation which can lead to watery eyes. This can be treated with eye drops like artificial tears. Clinical trial data has shown that Selenium supplementation can have a beneficial effect on the disease process in mild conditions. Stopping smoking is a key factor. The aim of treatment is to prevent severe disease that would the require surgery.

Surgical options are usually offered once the disease is in the burnt out phase. Visual loss is a rare condition associated with the disease and this is a case where an emergency orbital decompression may be required.

In the burnt out phase bulging can be treated with an orbital decompression, double vision may be amenable to eye muscle surgery and eyelid retraction can be treated with steroid injections or eyelid surgery.

Is the disease permanent?

The disease rarely remains permanently active and will eventually burn out. The damage caused during the active phase can be permanent and the main aim of treatment is to try to prevent permanent damage and to offer treatment options in the burnt out phase should this occur.

The aim of treatment in this phase it to restore the facial appearance prior to getting the illness with different types of surgery tailored to the individual. Surgical options include surgery to the eye socket, eyelids and eye muscles depending on what has been affected and what is desired by the patient.

Does thyroid eye disease go away?

The disease process will eventually burn out and he aim of treatment is to minimise the risk of severe disease and maintain healthy tissue around the eye muscles and the eye socket.

How long does it take for the disease to burn out?

The disease starts with an active phase that can last for 18 months or longer and then reaches a burn out phase. The aim is treat the active disease to prevent or minimise any disfigurement that can develop until the disease process burns out. Smoking is a key factor that makes the active phase more significant and last for longer meaning a greater risk of eye symptoms such eyelid retraction, scar tissue to the extraocular muscles causing double vision, orbital inflammation and fatty tissue deposition that can lead to bulging or proptosis of the eyes.

What is an orbital decompression?

This is a surgical procedure performed under general anesthesia that aims to treat bulging of the eyes. It is a form of reconstructive surgery. It increases the orbital volume, most commonly with a bony decompression. Here parts of the orbital walls that form the eye socket are removed to increase the space within the socket. The orbital contents are then able to rest back in a more natural position and it is used to treat severe proptosis. This can be combined with fat removal from within the socket to allow the eye to rest back further if required.

A unilateral wall decompression is where one wall of the socket is decompressed - most commonly the lateral wall or medial wall.

A lateral wall decompression is a surgical treatment where an incision is made at the lateral aspect of the eyelid in the skin crease or the corner of the eyelid known as the lateral canthus to access the bony wall. Care is taken to not disturb the lateral rectus muscle which helps move the eyeball.

A medial wall decompression is a surgical technique where an incision is made on the inside of the eyelid near the nose behind a bony landmark known as the posterior lacrimal crest. The medial wall is then accessed and the bone is removed. The medial wall can also be accessed with endoscopic sinus surgery. This form of endoscopic orbital decompression is most commonly used in the rare case of compressive optic neuropathy which results in a reduction in visual acuity and visual loss.

Most cases of decompression consist of both the medial and lateral walls being decompressed. Less common is a triple wall decompression where the orbital floor is accessed from the orbital rim. The floor is then decompressed with an incision inside the lower eyelid to the orbital rim allowing the contents in the orbit to expand into the maxillary sinus below.

If there is double vision from thyroid disease this would need treatment with strabismus surgery after the decompression surgery is allowed to heal.

How long does the operation take?

The amount of time taken to perform the surgery depends on whether one, two or three walls need to be decompressed. The surgery can take between two and three hours and is performed under general anesthesia.

Is the surgery painful?

There can be some pain for a day or two following the surgery and this is usually treated with mild painkillers such as paracetamol or co-codamol.

How safe is orbital decompression surgery?

The surgery is generally considered to be safe and helps to restore any bulging of the eyes. It is associated with risks of double vision which tends to settle and very rarely loss of vision. It is a form of cosmetic surgery that helps restore any bulging of the eyes in cases where there appearance significantly affects their quality of life. Mr Ahmad Aziz will be able to explain these risks and benefits at his London clinic.

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